Highlights

Groups issue update on management of PCI and STEMI

Updated guidelines for managing ST-elevation myocardial infarction (STEMI) and percutaneous coronary intervention (PCI) call for integrating prasugrel into treatment and for new standards on efficient transfer of patients needing PCI.

The update, compiled by the American College of Cardiology, the American Heart Association and the Society of Cardiovascular Angiography and Interventions, noted new evidence about prasugrel but does not explicitly endorse its use over clopidogrel. A recent large trial found that prasugrel reduced nonfatal MIs in STEMI patients undergoing PCI, compared with clopidogrel, but also increased the risk of bleeding, the authors said. In addition, there is not yet enough information to guide identification of patients who might do better with prasugrel, they added.

The authors also highlighted the importance of speeding transfer to PCI-capable facilities for patients with high-risk features such as high bleeding risk from fibrinolytic therapy and presentation more than four hours after symptom onset. They urged communities to develop regional systems of STEMI care, such as the AHA’s “Mission: Lifeline” initiative, which encourages closer cooperation among pre-hospital emergency services and cardiac care professionals.

Other recommendations in the update include the following:

Use of a glycoprotein IIb/IIIa agonist cannot be recommended as routine therapy for dual-antiplatelet therapy with unfractionated heparin or bivalirudin as the anticoagulant;

There is insufficient evidence to recommend the use of dual antiplatelet therapy with proton-pump inhibitors in the setting of acute coronary syndrome;

Bivalirudin is useful for primary PCI in STEMI regardless of whether the patient received pretreatment with unfractionated heparin;

Early glycoprotein IIb/IIIa therapy is reasonable in patients who are at high risk of thrombotic events relative to bleeding risk.

ACOG guidelines delay cervical cancer screening start, interval

Women should have their first cervical cancer screening at age 21 and can be rescreened every two or three years instead of annually, according to revised, evidence-based guidelines issued by the American College of Obstetricians and Gynecologists (ACOG).

The ACOG now recommends that women from ages 21 to 30 be screened every two years instead of annually, using either the standard Pap test or liquid-based cytology. Women age 30 and older who have had three consecutive negative cervical cytology test results may be screened once every three years with either the Pap test or liquid-based cytology. Women with certain risk factors may need more frequent screening, including those who have HIV, are immunosuppressed, were exposed to diethylstilbestrol in utero, and have been treated for cervical intraepithelial neoplasia (CIN) 2, CIN 3, or cervical cancer.

Moving the baseline cervical screening to age 21 is a conservative approach to avoid unnecessary treatment of adolescents, which can have economic, emotional, and future childbearing implications, the ACOG reported in a press release. The guidelines were published in the December issue of Obstetrics & Gynecology. The ACOG previously recommended that cervical screening begin three years after first sexual intercourse or by age 21, whichever occurred first.

Routine cervical cytology testing should be discontinued in women regardless of age who have had a total hysterectomy for noncancerous reasons, as long as they have no history of high-grade CIN, the ACOG noted.

The ACOG's recommendations on the upper age limit for discontinuing cervical cancer screening remain the same. It is reasonable to stop cervical cancer screening at age 65 or 70 among women who have three or more negative cytology results in a row and no abnormal test results in the past 10 years, the press release said. The ACOG also recommends that women who have been vaccinated against HPV should follow the same screening guidelines as those who have not.

Two new algorithms that rely on detailed patient histories rather than lab tests or clinical measurements improved on the traditional method of predicting fracture risk in primary care populations, a study reported.

Researchers looked at more than 2 million women and men age 30 to 85 who were treated at general practices in England and Wales. Two prediction algorithms, called QFracture Scores, were effective in identifying patients at high risk for hip fracture and, to a lesser extent, osteoporotic fracture, compared with an older fracture risk assessment algorithm (FRAX). The new algorithms incorporated the FRAX variables and added others, such as history of falls, type 2 diabetes, cardiovascular disease, asthma, use of hormone therapy and use of tricyclic antidepressants. All variables used were either known by the patient or available in the patient’s clinical record. The results were published online Nov. 19 in BMJ.

The authors noted that, unlike FRAX, the QFracture Score can be used in younger patients; can estimate risk at one, two and five years in addition to the traditional 10-year risk; and can be used to predict risk in patients without a history of fracture. The new algorithm has the potential to better estimate individual risk by incorporating more of the patient’s history, the authors said.

Potential limitations of the QFracture Score include not taking bone mineral density into account and possibly making implementation more difficult because of the increased number of variables, the authors said. However, they anticipated that the scores likely would be integrated into computer systems that automatically extract the variables and perform risk calculations.

Test yourself

MKSAP Quiz: recurring cough and dyspnea

A 21-year-old man is evaluated for a 4-hour history of cough and dyspnea after spending the day moving stored hay. A college student, he lives with his parents and siblings on the dairy farm. No one else in the family has similar symptoms. He actively participates in small grain production, soybean grinding for animal feed, and the cutting, baling, and storage of hay. He has had similar episodes the past two summers; each time he was hospitalized for atypical pneumonia, and his symptoms resolved quickly with antibiotics and inhaled bronchodilators.

On physical examination, his temperature is 38.4°C (101.1°F), his blood pressure is 142/84 mm Hg, and his respiration rate is 22/min. He has a few bibasilar crackles. There is no jugular venous distention or peripheral edema. Chest radiograph shows patchy infiltrates in the lower lobes and right middle lobe. Complete blood count shows a leukocyte count of 14,500/µL with 11,400 polymorphonuclear cells, 200 band forms, and 150 eosinophils.

Cardiology

High-dose ARB reduced death, complications from heart failure

Increasing the dose of an angiotensin-receptor blocker (ARB) lowered the rate of complications and death in patients with heart failure and reduced left ventricular ejection fraction, according to the results of a recent large trial.

The double-blind trial involved more than 3,800 patients in 30 countries who had New York Heart Association class II-IV heart failure, left ventricular ejection fraction (LVEF) of 40% or less and intolerance to angiotensin-converting enzyme (ACE) inhibitors, defined as withdrawal of the drugs because of cough, symptomatic hypotension, azotemia, hyperkalemia, taste disturbance, gastrointestinal upset or rash. Patients were randomized to receive losartan, 150 mg or 50 mg daily. After four to seven years of follow-up, 43% of patients in the high-dose group died or were admitted for heart failure, compared with 46% in the low-dose group. Renal impairment, hypotension, and hyperkalemia were more common in the high-dose group but rarely led to discontinuing treatment. The results of the study, which was funded by Merck, were published online Nov. 17 in The Lancet.

The results suggest that higher doses of an ARB are necessary to achieve maximum benefit in this population of heart failure patients, the authors said. They noted that the 150-mg dose achieved a 13% reduction in admission for heart failure compared with the lower dose.

The authors acknowledged that the benefits of the higher dose must be weighed against the increased frequency of adverse events. An accompanying editorial also noted that the findings do not apply to patients who are tolerant to ACE inhibitors and don't indicate whether a high-dose ARB is better than an ACE-inhibitor strategy or whether maximizing the dose of one ARB is better than using several agents. In addition, it is not clear whether the findings have implications for other renin-angiotensin-aldosterone system blockers.

Americans have lower LDL but no improvements in screening

The percentage of Americans with high LDL cholesterol levels has decreased since 1999, but screening rates have not improved, a new study found.

Using data from the National Health and Nutrition Examination Survey (NHANES), researchers analyzed LDL levels among more than 8,000 fasting adults age 20 or older. High LDL was defined as a level above the goal for each risk category according to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III). In 2005-2006, 21.2% of study participants had high LDLs, compared to 31.5% in 1999-2000. Over the same time period, self-reported use of lipid-lowering medication increased from 8.0% to 13.4%. Screening rates did not change significantly, staying under 70%, well below the Healthy People 2010 goal of 80%.

The lack of consensus among guidelines about the age to begin screening may be contributing to the low rates, the study authors suggested. Clinicians may also have difficulty with the complexity of current NCEP ATP III guidelines, which an editorial that accompanied the study described as "cumbersome." Assessment of risk factors, rather than an LDL cutoff, could be a more effective criterion for determining which patients to treat with statins, the editorialists said. The editorial also suggested that patients be treated not to a numerical goal, but a looser target such as a 50% reduction in LDL, given the linear benefits of cholesterol lowering.

A commentary, published in the same Nov. 18 issue of the Journal of the American Medical Association, proposed an alternate approach: lipid therapy for all patients (perhaps as part of a polypill) based on an age threshold. The low cost and evidence-supported benefits of statins could justify such a practice, and the possibility should be investigated by researchers, the authors of the commentary concluded.

FDA update

Patch approved to treat shingles pain

A medicated skin patch containing capsaicin (Qutenza 8%) was approved last week to treat pain from post-herpetic neuralgia in patients with shingles, the FDA announced.

Lower concentrations of capsaicin, a compound found in chili peppers, are available over the counter, but this patch is the first pure, concentrated, synthetic capsaicin-containing prescription drug to undergo FDA review. The most frequently reported adverse drug reactions included pain, swelling, itching, redness, and bumps at the application site.

The patch must be applied to the skin by a health care professional since placement can be quite painful, requiring use of a local topical anesthetic, as well as additional pain relief such as ice or use of opioid pain relievers, according to the FDA. The patient must also be monitored for at least one hour since there is a risk of a significant rise in blood pressure following patch placement.

FDA warns against giving clopidogrel with PPIs

Clopidogrel (Plavix), an anti-clotting medication, and omeprazole (Prilosec/Prilosec OTC), a proton-pump inhibitor (PPI), should not be used together, the FDA warned health care professionals last week.

The notification, which came with a labeling change for clopidogrel, was based on new manufacturer data showing that when the drugs are taken together, the effectiveness of clopidogrel is reduced. Patients at risk for heart attacks or strokes who use clopidogrel to prevent blood clots will not get the full effect of this medicine if they are also taking omeprazole, the FDA said.

The agency also warned that separating the dose of clopidogrel and omeprazole in time will not reduce this drug interaction. Other drugs that are expected to have a similar effect and should be avoided in combination with clopidogrel include: cimetidine, fluconazole, ketoconazole, voriconazole, etravirine, felbamate, fluoxetine, fluvoxamine, and ticlopidine. There is no evidence that other drugs that reduce stomach acid, such as most H2 blockers (ranitidine [Zantac], famotidine [Pepcid], and nizatidine [Axid], with the exception of cimetidine [Tagamet and Tagamet HB—a CYP2C19 inhibitor]) or antacids, interfere with the anti-clotting activity of clopidogrel.

The FDA does not have sufficient information about drug interactions between clopidogrel and PPIs other than omeprazole and esomeprazole to make specific recommendations about their co-administration.

CMS update

Medicare extends provider enrollment period

Last week, CMS announced it would extend the 2010 Annual Participation Enrollment period until Jan. 31, 2010.

The effective date for any status change, however, will still be Jan. 1, 2010. This means that if you choose to change your status from participating to non-participating after Jan. 1, Medicare's non-participating provider conditions will be in force for your claims with dates of service on or after Jan. 1.

Additional information about provider enrollment is available on the CMS Web site.

From the College

Member survey: Will USPSTF mammogram guidelines change your practice?

The U.S. Preventive Services Task Force (USPSTF) released new mammography guidelines in the November 17th issue of Annals of Internal Medicine.

Please take a few minutes to fill out the survey posted on ACP’s Web site to share your opinion regarding whether the new recommendations will impact how you advise patients about breast cancer screening. The survey also contains questions for nonphysicians to measure the impact of the guideline on the general public and whether women plan to change the frequency of their mammography exams.

Cartoon caption contest

And the winner is …

ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by Harrison Weed, FACP, who will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 158 ballots online to choose the winning entry. Thanks to all who voted!

MKSAP answer and critique

The correct answer is C) Spontaneous improvement followed by recurrence after returning to the farm. This item is available online to MKSAP 14 subscribers in the Pulmonary and Critical Care Medicine section, Item 10.

This patient likely has hypersensitivity pneumonitis, a specific allergic reaction in the lower respiratory tract to inhaled low-molecular-weight antigens. The clinical presentation is typically one of recurrent acute episodes of fever, cough, and dyspnea that begin 4 to 6 hours after antigen exposure and resolve spontaneously 24 to 48 hours after antigen avoidance. The diagnosis is suggested by 1) compatible clinical presentation coupled with a history of exposure to a potential antigen, 2) demonstration of specific immunity to that antigen, and 3) resolution of disease with antigen avoidance or recurrence of disease with repeated exposure.

Environmental antigen challenges have been used to confirm the diagnosis of hypersensitivity pneumonitis, but there are no widely accepted protocols or standardized antigen preparations. A clinical response to prolonged antigen avoidance or disease recurrence on repeated exposure is as helpful where practical. A specific immune response may be confirmed by the detection of circulating precipitating antibodies to the antigen of interest. However, most people in the exposed population may develop precipitating antibodies but only a minority develop clinical signs of the disorder. Therefore, the presence of antibody is supportive but not sufficient evidence to make the diagnosis of hypersensitivity pneumonitis.

The finding of a precipitin band in a lifelong farmer does not of itself imply a diagnosis of hypersensitivity pneumonitis. The disease represents a specific immunologic response in susceptible persons to repeated antigen exposure, which distinguishes it from the nonspecific lower respiratory tract inflammation seen after a high-level organic dust exposure (as occurs in mycotoxicosis, endotoxin inhalation, and organic toxic dust syndrome). Thus, simultaneous disease in similarly exposed persons argues against a diagnosis. Hypersensitivity pneumonitis is not associated with immediate skin test reactivity because it is not IgE-mediated. The demonstration of reversible airflow obstruction is a nonspecific finding and can occur with asthma, postinfectious bronchial hyperreactivity, endotoxin inhalation, or hypersensitivity pneumonitis.

Key Points

The clinical presentation of hypersensitivity pneumonitis is typically recurrent acute episodes of fever, cough, and dyspnea that begin 4 to 6 hours after antigen exposure and resolve spontaneously 24 to 48 hours after antigen avoidance.

Reversible airflow obstruction is a nonspecific finding that can occur with asthma, postinfectious bronchial hyperreactivity, endotoxin inhalation, or hypersensitivity pneumonitis.

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright 2009 by the American College of Physicians.

Test yourself

A 66-year-old man is evaluated for a persistent rash for 6 years' duration. The rash waxes and wanes in severity, and it becomes pruritic only after he becomes hot and sweating, such as when he mows the lawn or exercises. It has always been limited to his back and lower chest. He has never treated it. The patient is otherwise well, has no other medical problems, and takes no medication. Following a physical exam, what is the most likely diagnosis?

Internal medicine physicians are specialists who apply scientific
knowledge and clinical expertise to the diagnosis, treatment, and
compassionate care of adults across the spectrum from health to complex
illness. ACP Internist provides news and information for internists
about the practice of medicine and reports on the policies, products and
activities of ACP. All published material, which is covered by
copyright, represents the views of the contributor and does not reflect
the opinion of the American College of Physicians or any other
institution unless clearly stated.